When tinkering with health reform, values matter

n Tuesday night, President Trump called on Congress to replace Obamacare with health care reforms “that expand choice, increase access, lower costs, and at the same time provide better health care.” Few people will disagree with the president’s stated principles. Yet, as we know, and as Trump recently discovered, health reform is more complicated than that. In debates over health reform, the devil is in the details, and these details are largely driven by ideological values.

Trump’s statement reflects something that health policy experts call the Triple Aim. Before that appeared, health policy wonks like us talked about the three-legged stool of health care — access, cost, and quality — and often joked that you can have any two at the expense of the third.

Imagine one end of the spectrum — we’ll call it the left — where access to health care, whether through insurance or some other means, is a fundamental right. You can call this single-payer or even national health insurance. Either way, it represents a variety of arrangements that guarantee health insurance for everyone. At the other end of the spectrum, access to health care is a privilege, something left to the market to decide who gets it and who doesn’t.

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At that end, individuals and families can buy health insurance if they have the means, and there’s some fragmented safety-net systems in place to (hopefully) catch the most vulnerable folks who can’t. This essentially describes the pre-Obamacare health care environment. The Affordable Care Act moved us along the spectrum toward more access and better health insurance, but our system today is still far from approaching health care as a fundamental right.

The debate about health care being waged today isn’t about either end of this spectrum. Instead, it’s focused on the right of the middle, debating about how to tinker with the key elements that were put in place by Obamacare: Medicaid expansion for low-income childless adults, premium tax credits in the exchanges up to 400 percent of the poverty line, protections for people with preexisting conditions, and mandating that individuals purchase health insurance.

When you examine the key differences between how the ACA expanded access and improved health care and how leading Republican proposals claim to do the same, you can see a stark contrast in values.

These value-laden debates are largely about three fundamental questions: What should be the role of government in health care? Who should decide whether an individual has coverage? How much should health insurance redistribute the costs of care?

The role of government. The ACA expanded the government’s role in providing health insurance and access through Medicaid. The goal was to create a more consistent safety net for poor Americans than was previously allowable by Medicaid eligibility rules, and to provide robust federal funding to support states. Trump’s take on Medicaid Tuesday night was intriguing. He said that “we should give our state governors the resources and flexibility they need with Medicaid to make sure no one is left out.”

His “flexibility” is likely a reference to Republican Medicaid proposals for per capita allotments and block grants. However, giving state governors the “resources” to “make sure no one is left out” seems inconsistent with Republican proposals that call for reducing the federal match rate for the Medicaid expansion group and capping the amount of federal money spent on Medicaid. Republican proposals clearly advocate walking back the federal government’s role in Medicaid. So Trump’s rhetoric last night, supported by Paul Ryan’s smiles, nods, and standing applause on this point, muddies the waters a bit.

Individual decision-making. This one is clear. Both Trump and the Republican Party currently oppose the individual mandate, coming down on the side that government should not interfere with individual choice and liberty. In fact, Representative Mike Burgess from Texas went so far as to say, “if the numbers [of people with health insurance] drop, I’d say that is a good thing because we’ve restored personal liberty, and I’m always for that.”

This emphasizes the value of liberty over access to health care. Importantly, how policies are interpreted through the lens of ideological values can change. For example, in Massachusetts under Republican Governor Mitt Romney, we saw the Republican principle of personal responsibility embedded in support for the individual mandate — no more “free riders.”

Redistribution. Who should pay more for health insurance, and how much should the costs of care be redistributed across everyone? The premium tax credits created by Obamacare are available on a sliding scale for people between 100 and 400 percent of the poverty line. In other words, one value of the ACA was to give poor people more money to help cover the cost of health insurance.

In contrast, the leaked draft ACA replacement bill and other Republican proposals replace this approach with refundable tax credits to purchase health insurance, and they set the amount based on age: Older people get larger credits than younger individuals. However — and this often gets lost in this conversation — because of the way the tax credits were set up in the ACA (namely, “people pay no more than a required percentage of income for the second lowest cost silver plan for their age in their area”) and because health insurers in the exchange can set premiums for older people that cost no more than three times that of younger people, under the ACA low-income adults are already receiving age-adjusted premium tax credits. So, the ACA also values helping older people.

Even more, the current Republican proposals suggest that redistribution is not the role of health insurance. Instead, while younger people would be able to purchase cheaper health plans (which is why they need to give a little more support to older adults), the sickest among us would be moved into high-risk pools, now cleverly renamed “state innovation grants.” Regardless of the name, this is a notoriously ineffective proposition. In a nutshell, the values in the Republican plans suggest that they do not believe that the purpose of health insurance is to redistribute costs from the healthy to the sick.

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While the changes being proposed for health care are more at the level of tinkering than comprehensive reform, the differences in values have significant implications for access to health care. The Democrats’ response to Trump’s speech last night by former Kentucky Governor Steve Beshear was accurate when he stated that, “Every Republican idea to replace the Affordable Care Act would reduce the number of Americans covered.”

When Trump talks about “lower costs,” this specifically means reducing premiums for health insurance. Yet that alone will not equate to “better health care.” Instead it will lead to higher deductibles and out-of-pocket payments, and fewer protections for consumers.

Making these seemingly shared principles — to “increase access, lower costs, and at the same time provide better health care” — a reality is not easy. But if Trump and his party are able to reconcile their rhetorical inconsistencies and some version of these Republican proposals come to fruition, that three-legged stool of access, cost, and quality, which had been somewhat stabilized by the ACA, will again become quite rickety.

Signe Peterson Flieger, PhD, is an assistant professor of public health and community medicine at Tufts University School of Medicine. Harris A. Berman, MD, is dean of Tufts University School of Medicine, where he is professor of internal medicine and of public health and community medicine.